Quote Request and Census Form
Attention: Group Health Quotes
Springs Health Plans
2165 Hoodoo Dr. Email: email@example.com
Colorado Springs, Colorado 80919 Fax To: 719-884-1254
Highlighted information in bold letters is required. Missing information may delay the quote.
Company Name: Effective Date: # of Full Time Employees:
Address Contact Name:
City: State: Zip Code: Fax: Phone:
SIC Code and/or Industry Type: Current Carrier:
Employee Name or Initials Employ Employee’s Elected If coverage Waived/COBRA
ee’s Date of Birth Coverage* selected is (if applicable)
Please do not enter Gender or Age (see below) EC or EF
employees’ dependents’ M/F enter
names in this column.
# of Children
** Elected Coverage:
Employee Only = E Employee& Spouse only = ES Employee & Child(ren) only = EC Employee & Family = EF
Please add additional pages as necessary. If you only use one page you are not subject to COBRA. If you add one or more
pages, COBRA rules apply. When you apply for your group insurance a copy of your UITR (Unemployment Insurance Tax
Return) will have to be submitted with your application.